coronary artery disease

Coronary Artery Disease CAD Nursing Diagnosis Care Plan

Coronary Artery Disease CAD Nursing Diagnosis Care Plan Pathophysiology and NCLEX review

Coronary artery disease (CAD) is a medical condition which involves damage to the major blood vessels that provide the heart with oxygen and nutrients. CAD is usually caused by cholesterol deposits called plaques that cause inflammation and narrowing of the coronary arteries.

The buildup of plaque on the arterial walls narrow the coronary arteries, thereby decreasing the blood flow to the heart. When one of the coronary arteries is completely blocked, the person is likely to experience a heart attack. The classic sign of CAD is chest pain called angina.

Signs and Symptoms

  • Angina – pain or discomfort located on the middle or left side of the chest. The patient will describe a CAD angina as: “tight”, “crushing”, or “heavy”. The patient may also verbalize that it feels like someone is standing on their chest, or that there is a feeling of pressure. This may be triggered by emotional or physical stress. The pain may radiate to the neck, shoulder, back, arm., or jaw.
  • Shortness of breath
  • Tachycardia
  • Hypertension
  • Tachypnea
  • Palpitations
  • Nausea (especially in women)
  • Dizziness
  • Sweating
  • Restlessness

Causes

Coronary artery disease starts when there is injury or damage to the inner layer of coronary arteries. Cholesterol-containing deposits or “plaques” clump the site of damage. The medical term for plaque buildup is atherosclerosis. When there is a rupture or break in the plaque, platelets arrive at the injury site in an attempt to repair that part of the artery. The clump of platelets called thrombus may block the artery, causing an obstruction of blood flow. This eventually results into myocardial infarction (M.I.), also known as heart attack.

There are several risk factors that may promote the buildup of plaque in a coronary artery. These include:

  • Smoking
  • High blood pressure
  • High cholesterol diet
  • Sedentary lifestyle
  • Diabetes or insulin resistance

Complications

  1. Arrythmias. Abnormal heart rhythms such as atrial fibrillation may result from the decreased blood supply in the heart. Irregular heartbeats may result to formation of more blood clots. These thrombi can travel to other parts of the body and become embolus/ emboli. When the embolus reaches the brain, the patient may suffer from stroke.
  2. Myocardial Infarction, acute coronary syndrome (ACS), or heart attack. Total blockage of a coronary artery may result to the lack of blood flow to the cardiac muscle.
  3. Heart Failure. Since the coronary arteries supply the heart with oxygen- and nutrient-rich blood, blockage in them may weaken the heart. This eventually leads to failure of the heart to supply blood to the rest of the body tissues.

Diagnostic Tests

  • Blood tests – total lipid profile (fasting for 10 to 12 hours) and lipoprotein blood test (non-fasting) to determine the risk for CAD
  • Electrocardiogram (ECG)
  • Echocardiogram – utilizes sound waves to create images of the heart
  • Exercise stress test – use of ECG while the patient is on a treadmill or a stationary bike. This may also be used with an echo. Nuclear stress tests is a more advanced version where in a tracer is injected into the bloodstream for the cameras to create images.
  • Cardiac catheterization and angiogram
  • Cardiac CT scan

Treatment

  1. Medications. The following drugs may be used to treat coronary artery disease, as well as the accompanying chest pain (angina):
  2. Blood thinning agents such as Aspirin – to reduce the ability of the blood to clot, so that the blood flows easier through the narrowed arteries.
  3. Nitrates – to relax the blood vessels.
  4. Anti-cholesterol drugs (e.g. statins) – to reduce the deposits on the arterial walls
  5.  Beta blockers – to decrease the cardiac demand for oxygen by means of lowering the heart rate and blood pressure levels
  6. Calcium channel blockers – used in combination with beta blockers
  7. Ranolazine – to treat angina
  8. Surgery. Surgical interventions are required if the medical team believes that an urgent, more aggressive treatment for CAD is needed. These surgeries include
  9. Coronary artery bypass surgery – creation of a graft to reroute the blood flow away from the diseased artery)
  10. Angioplasty with stent placement – also known as percutaneous coronary revascularization which involves the insertion of a catheter into the affected artery followed by inflation of balloon and insertion of a stent to keep the blood vessel open.
  11. Lifestyle changes. Smoking is one of the biggest risk factors of CAD. The nicotine in cigarettes facilitate the constriction of blood vessels, which then increases the cardiac workload. This eventually damages the lining of the coronary arteries, as well as other blood vessels. Another lifestyle change is to commit to a low cholesterol, low sugar diet to control cholesterol and blood glucose levels. Foods rich in omega-3 fatty acids such as fish, soybeans, and flaxseeds are recommended. Regular taking of prescribed blood pressure medications also helps control hypertension. Increasing physical activity by doing at least 150 minutes of moderate aerobic exercises will help promote an active lifestyle. Lastly, learning stress management techniques is helpful in lowering the risk for CAD. Some alternative medicine may help, including fish oil, flaxseed oil, canola oil, and soybean oil.

Nursing Care Plans for Coronary Artery Disease

  1. Decreased cardiac output related to the disease process of coronary artery disease (CAD) as evidenced by fatigue and inability to do ADLs as normal

Desired outcome: The patient will be able to maintain adequate cardiac output.

InterventionsRationale
Assess the patient’s vital signs and characteristics of heartbeat at least every 4 hours. Assess heart sounds via auscultation. Observe for signs of decreasing peripheral tissue perfusion such as slow capillary refill, facial pallor, cyanosis, and cool, clammy skin.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment. Heart murmur sounds is an important sign of endocarditis. The presence of signs of decreasing peripheral tissue perfusion indicate deterioration of the patient’s status which require immediate referral to the physician.
Administer prescribed medications for coronary artery disease.    Aspirin – to reduce the ability of the blood to clot, so that the blood flows easier through the narrowed arteries. Nitrates – to relax the blood vessels. Anti-cholesterol drugs (e.g. statins) – to reduce the deposits on the arterial walls  Beta blockers – to decrease the cardiac demand for oxygen by means of lowering the heart rate and blood pressure levels Calcium channel blockers – used in combination with beta blockers Ranolazine – to treat angina
Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.To increase the oxygen level and achieve an SpO2 value of at least 94%.
Educate patient on stress management, deep breathing exercises, and relaxation techniques.Stress causes a persistent increase in cortisol levels, which has been linked to people with cardiac issues. Chronic stress may also cause an increase in adrenaline levels, which tend to increase the heart rate, respiratory rate, and blood sugar levels. Reducing stress is also an important aspect of dealing with fatigue.
CAD Nursing Care Plan 1
  • Nursing Diagnosis: Acute Pain related to decreased myocardial blood flow as evidenced by  pain score of 10 out of 10, verbalization of pressure-like/ squeezing chest pain (angina), guarding sign on the chest, blood pressure level of 180/90, respiratory rate of 29 bpm, and restlessness

Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.

InterventionsRationale
Administer prescribed medications that alleviate the symptoms of angina.Aspirin may be given to reduce the ability of the blood to clot, so that the blood flows easier through the narrowed arteries. Nitrates may be given to relax the blood vessels. Other medications that help treat angina include anti-cholesterol drugs (e.g. statins), beta blockers, calcium channel blockers, and Ranolazine.
Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication.  To monitor effectiveness of medical treatment for the relief of angina. The time of monitoring of vital signs may depend on the peak time of the drug administered.  
Elevate the head of the bed if the patient is short of breath. Administer supplemental oxygen, as prescribed. Discontinue if SpO2 level is above the target range, or as ordered by the physician.To increase the oxygen level and achieve an SpO2 value of at least 94%.
Place the patient in complete bed rest during angina attacks. Educate patient on stress management, deep breathing exercises, and relaxation techniques.Stress causes a persistent increase in cortisol levels, which has been linked to people with cardiac issues. The effects of stress are likely to increase myocardial workload.
Coronary Artery Disease Nursing Care Plan 2

Other nursing diagnoses:

  • Activity Intolerance
  • Deficient Knowledge
  • Anxiety

NCLEX Practice Quiz 5 Questions with Rationales – Randomized

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Results

#1. An 80-year old male patient comes into the medical ward with nausea, a urine output of 10 mL per hour, and weight gain of 5kg in the least 2 months. The patient should be investigated for:

Answer: A Rationale: Right-sided heart failure, also known as pulmonary heart disease or cor pulmonale, is a condition wherein there is less blood pumped into the lungs from the right side of the heart. As a result, the patient might have secondary signs of low urine output, nausea, and weight gain.  

#2. . A 67-year old patient is admitted with congestive heart failure (CHF). Which of the following medications will the patient need to elevate the level of cardiac output by increasing the contractility of the ventricles?

Answer: C

Rationale: Inotropic agents work by increasing the force of contractions of the cardiac muscles. This elevates the ability of the ventricles to contract, causing a rise in cardiac output. Epinephrine, norepinephrine, and dobutamine are some examples of inotropes.

#3. A 69-year old female patient is diagnosed with ischemic heart disease. The doctor prescribes which of the following medications to protect the ischemic myocardium by blocking sympathetic nerve stimulation?

Answer: B

Rationale: Beta adrenergic blockers such as bisoprolol and atenolol blocks the beta receptors in the myocardial tissues. This reduces the response to the sympathetic nerve stimulation, as well as the catecholamines. The workload of the heart is subsequently reduced, and the oxygen demand of the myocardial tissues are reduced.

#4. A patient is suspected to have left-sided heart failure. All of the following signs and symptoms may be observed in this patient initially, except:

Answer: A

Rationale: Pulmonary symptoms such as shortness of breath, dry and nonproductive cough, pulmonary congestion and dyspnea are all associated with left-sided heart failure. Right-sided heart failure is characterized by edema of the lower extremities and congestion of peripheral and visceral tissues.

#5. A patient is newly diagnosed with heart failure. Which of the following medications can help control the heart failure and increase cardiac output, without little effect on the heart rate and blood pressure?

Answer: C

Rationale: Lisinopril is an ACE-inhibitor, which is a group of first-line cardiac drugs that reduce ventricular filling pressures and increase cardiac output, controlling heart failure. ACE inhibitors have little effect on the heart rate and blood pressure.

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